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Anesthesia & Coexisting Disease > Ex2 Vascular Dx > Flashcards

Ex2 Vascular Dx Flashcards

1
Q

Thoracic/Abdominal aorta is most often

A

aneurysmal

  • outpouch of tissue (all 3 layers) that fills with blood
  • 50% increase in diameter
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2
Q

TAA - rupture - survival rate

A

25%

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3
Q

TAA - dissection: initiating event

A

tear in intima

-forms false channel

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4
Q

TAA - dissection most commonly happens in

A

thorax in the ascending aorta

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5
Q

most common risk factors in TAA

A

80% - Atherosclerosis
19% - family hx of aneurysmal dx
Smoking, Male, Older age, HTN

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6
Q

Inherited disorders assoc. with TAA

A

Marfans Syndrome
Ehler’s Danlos syndrome
(ED syn: flexible joints, skin elastic skin, bruise easily)
Bicuspid aortic valve

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7
Q

marfans syndrome

A 
hereditary connective tissue disorder 
Fibrilin-1 gene - matrix destruction 
CHEMICAL function (not mechanical) - causes structural weakness in aorta
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8
Q

Bicuspid aortic valve

A

most common congenital anomaly resulting in aortic dissection/dilation

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9
Q

Crawford Classification Type I

A

All/most of descending thoracic aorta + upper abdominal aorta

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10
Q

Crawford Classification Type II

A

All/most of descending thoracic aorta + most of abdominal aorta

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11
Q

Crawford Classification Type III

A

Involves lower portion + abdominal aorta

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12
Q

Crawford Classification Type IV

A

Most of abdominal aorta including visceral segment

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13
Q

Most difficult TAA to treat

A

Crawford II + III

*crosses diaphragm

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14
Q

Dissecting aneurysms are classified by

A

Debakey Classification

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15
Q

Debakey I

A

formed a false track all the way up/down entire length of aorta

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16
Q

Debakey II

A

Tear = ascending

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17
Q

Debakey IIIa

A

Tear = intimal + stays on descending aorta

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18
Q

Debakey IIIb

A

Tear = intima + entire length of that side

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19
Q

S/S TAA

A

Asymptomatic

*impingement of aneurysm on adjacent structure may cause symptomatology on assoc. location

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20
Q

TAA with s/s hoarseness

A

impingement on R laryngeal nerve

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21
Q

TAA with s/s stridor

A

Compression of trachea

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22
Q

TAA with dysphagia

A

compression of esophagus

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23
Q

TAA with facial edema

A

compression of superior vena cava

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24
Q

S/S TAA dissection

A

acute, severe, sharp pain in anterior chest, neck or between shoulder blades

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25
Q

TAA dissection presents with shock

A

(severe hypotension)
-prognosis = poor
decreased peripheral pulses

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26
Q

Complications of TAA dissection

A

stroke, ischemic peripheral neuropathy, paraplegia, MI, GI ischemia, renal artery obstruction
*cardiac tamponade

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27
Q

Diagnosis of TAA

A

CXR (widening mediastinum)

TE-Echo + doppler flow (highly sensitive+specific)

28
Q

predictors of post-thoracic aorta surgery

A

predictors of resp failure:

Smoking + COPD

29
Q

Tx TAA

A 
Surgical repair 
Type A
Ascending aorta
Aorta Arch
Type B if aneurysm > 5cm
Medical Tx: Type B < 5cm
30
Q

Type A Dissection

A

Ascending aorta +/- arch

31
Q

Mortality: Type A Dissection

A

27% after repair

56% if not repaired

32
Q

Type B dissection

A

Ascending aorta NOT involved

33
Q

Ascending + aortic arch dissection

A

emergent/urgent surgery

34
Q

TAA - which is associated with better outcomes?

A

Type B: Descending thoracic aortic dissection

35
Q

Which TAA requires cardiopulmonary bypass?

A

Aortic Arch
+hypothermia
+circulatory arrest
*neurological deficits post repair

36
Q

Most important risk of paraplegia/renal failure with aortic cross clamping

A

Duration of clamping aorta

*under 30 minutes = almost no paraplegia

37
Q

Risks assoc.: surgical resection of thoracic aortic aneurysm

A 
spinal cord ischemia
MI/HF
coagulopathy
renal failure 30%
respiratory failure 50%
38
Q

Lower 2/3 of spinal cord is supplied by

A

Artery of Adamkiewicz
(AAA)
Ischemia: Anterior spinal artery syndrome

39
Q

HD response to X clamping

A

Increased BP, SVR, preload (CVP, PAOP, LVED), CSF pressure, myocardial contractility, coronary blood flow
*no increase in HR means: decreased CO

40
Q

Tx - increase CO from X-clamp

A

Vasodilators: SNP, NTG

41
Q

Tx goal during X-clamp

A

Myocardial preservation

-decrease afterload, normalize preload, coronary blood flow, contractilty

42
Q

Blood flow distal to clamp depends on

A

perfusion pressure

43
Q

HD response to unclamping

A

decrease in SVR/BP
LVEDV decreases
CO changes - unclear
myocardial blood flow increases

44
Q

Goal during unclamping

A

Gradual decrease to avoid hypotension (metabolic waste/lactate buildup)

45
Q

Monitoring during TAA cross clamping

A

R radial A line

Femoral Artery A line

46
Q

Cerebral perfusion during TAA cross clamping is monitored via

A

R radial A line

47
Q

Renal/spinal cord perfusion during TAA cross clamp is monitored via

A

femoral artery A line

48
Q

Goal MAP above X-clamp

A

100mmHg

49
Q

Goal MAP below X-clamp

A

> 50 mmHg

50
Q

Monitor neurologic function during X-clamp

A

via SSEPs

51
Q

Monitor cardiac fxn during x-clamp via

A

TEE, pulm artery catheter

52
Q

How is renal protection performed in X-clamp for TAA?

A

40 Celsius LR + 25g mannitol/L directly into renal artery via surgeon

53
Q

post op management TAA

A

epidural analgesia: neuraxial opioids

do NOT want LA in epidural (masks anterior artery spinal syndrome)

54
Q

What is common and must be managed in post-op of TAA X-clamp?

A

HTN

Tx: NTG, SNP, labetalol, hydralazine, BB

55
Q

Tx AAA

A

surgery if AAA > 5.5 cm
Serial U/S: < 5.5 cm
if increasing in size >.6-.8 cm/year, surgery indicated
Smoking + close to threshold: surgery indicated

56
Q

Preop evaluation for AAA

A
  • optimize comorbid conditions
  • copd: minimize resp infxn, etc.
  • caution in severe resp/renal dysfxn
57
Q

1 cause of post-op deaths (AAA)

A

MI

58
Q

Classic triad of ruptured AAA

A

Hypotension
Back pain
Pulsatile mass

59
Q

Ruptured AAA - tx depends on

A

stable/unstable/suspected rupture

60
Q

Ruptured AAA - tx if stable

A
  • exsanguination may be prevented by clotting + tamponade effect of retroperitoneum
  • euvolemic resuscitation deferred
61
Q

ruptured AAA - tx if unstable

A
  • require immediate surgical intvn
  • give uncrossed/unmatched blood
  • no time to optimize preop conditions
62
Q

ruptured AAA - tx if suspected rupture

A

same as unstable

63
Q

AAA - invasive monitoring during surgery

A

PA catheter
Echo - assess response during/after X-clamp
GETA - benzo + narcotic

64
Q

AAA - when is epidural safe?

A

If PLANNED AAA repair

65
Q

Risk of AAA + TAA repair post-op

A

spinal cord injury

-from 12h-21d

66
Q

AAA vs. TAA main intra-op difference

A

AAA: need DL ETT

Anesthesia & Coexisting Disease (23 decks)

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